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--- gadolinium_and_renal_impairment [2010/07/02 00:55]
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-====== Gadolinium and Renal Impairment ======
-Updated 10.22.2008
-===== Background: =====
-It has been recognized recently that patients with severe renal insufficiency/renal failure are at increased risk for the development of Nephrogenic Systemic Fibrosis (NSF) when given gadolinium agents for MRI imaging. The reported incidence varies from 1% to 7% in patients with severe chronic kidney disease (CKD), particularly those on chronic dialysis.
-NSF has been reported with several gadolinium agents, although it is more strongly associated with some, specifically gadodiamide (Omniscan®). The occurrence of NSF increases with larger gadolinium doses (e.g. MRA) and repeat administration, in the higher risk categories.
-NSF occurs primarily in patients on chronic dialysis (hemo-, peritoneal) for their renal failure; therefore, it is found primarily in patients whose GFR is less than 15 ml/min.
-It has not been reported when the GFR is above 60 ml/min; and there is a theoretical risk when the GFR is between 60 and 30 ml/min. An increased number of cases have occurred in in patients with a GFR of less than 30 ml/min.
-Dialysis does clear gadolinium agents but in renal failure patients on chronic dialysis, at least 3 treatments would be necessary to clear all of the gadolinium.
-===== APPROACH TO IMAGING PATIENTS WITH GADOLINIUM: =====
-==== 1. If the GFR is greater than 60 ml/min ====
-Any agent may be utilized without risk.
-==== 2. If the GFR is less than 60 ml/min but greater than 30 ml/min ====
-Gadodiamide (Omniscan®), gadopentetate dimeglumine (Magnevist®) and gadoversetamide (OptiMARK®) should be avoided; the exam can be done with minimal risk, but risk/benefit must always be considered..
-==== 3. If the GFR is less than 30 but greater than 15 (e.g. patient is not on dialysis) ====
-The patient is at significant risk for NSF, but the risk is low with the “less risky” gadolinium agents. Risk-benefit should be discussed with the referring physician and the patient and informed consent of the patient should be obtained. (CT with iodinated contrast is not a good option in this group of patients since there is still residual renal function that may be severely damaged by a large dose of iodinated contrast).
-==== 4. If the patient is on dialysis ====
-  * Gadolinium-enhanced MRI should be avoided. MR without gadolinium should be considered as an initial study.
-  * If a contrast-enhanced examination is indicated and the patient is on permanent dialysis, an iodinated contrast CT should be the imaging study of choice.
-  * If MR with gadolinium must still be done, this should be discussed in detail with the clinician and patient and written informed consent obtained.
-  * Although dialysis can remove only a portion of the gadolinium, arranging for the gd-MR exam to be done immediately before a scheduled dialysis treatment might be beneficial, though this is not proven.

UW MSK Residents' Manual

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